S cott Haldeman DC, MD, PhD, FRCP(C), FCCS(C), FAAN holds the positions of, adjunct Professor, Department of Epidemiology, School of Public Health, University of California, Los Angeles, Clinical Professor, Department of Neurology, University of California, Irvine and Visiting Professor at both the Southern California University of Health Sciences and the Shanghai University of TCM. He is Past President of the North American Spine Society, the American Back Society, the North American Academy of Manipulative Medicine, and the Orange County Neurological Society. He is currently chairman of the Research Council of the World Federation of Chiropractic. He serves as President of World Spine Care, a non-profit organization with the goal of helping people in underserved regions of the world who suffer from spinal disorders. He sits on the editorial boards of eight journals. He has published over 200 articles or book chapters, over 70 scientific abstracts, and has authored or edited 8 books.
He is certified by the American Board of Neurology and Psychiatry, is a Fellow of the Royal College of Physicians of Canada and a Fellow of the American Academy of Neurology. He served on the US department of Health AHCPR Clinical Guidelines Committee on Acute Low Back Problems in Adults as well as 4 other Clinical Guidelines Committees. He presided over The Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders. He was awarded an honorary Doctor of Humanities degree from the Southern California University of Health Sciences and an honorary Doctor of Science degree from the Western States Chiropractic College. He received the David Selby Award from the North American Spine Society and the Lincoln Research Award. A resident of Santa Ana, California, he maintains an active clinical practice. In an interesting interview with The American Chiropractor (TAC), Dr. Haldeman tells what he's been up to with the World Spine Care program, as well as the role chiropractors should be looking to occupy with regard to spinal care.
TAC: Dr. Haldeman, what inspired you to become a chiropractor? Do you have a specific story?
Dr. Haldeman: I grew up in a chiropractic family. My father was a chiropractor and my grandmother was a chiropractor. As a matter of fact, my grandmother is considered the first chiropractor ever to practice in Canada. She obtained her chiropractic diploma in 1905 and practiced in Minnesota and then in Saskatchewan.
TAC: I'd imagine most people aren't aware of that.
Dr. Haldeman: My father was very active in chiropractic professional activities all his life. He was on the first Board of Directors of the Canadian Memorial Chiropractic College and was very active in establishing legislation in Canada. On moving to South Africa he took an active leadership role in the South African Chiropractic Association. I used to help in my father’s clinic and the whole family received regular adjustments. It was always assumed that I would follow in his footsteps and become a chiropractor.
TAC: So you followed that up and became a medical doctor. What were some of the influences that made you want to pursue that?
Dr. Haldeman: When I graduated from Palmer College, I was only 22 years old. On return to South Africa, I decided to further my studies and enroll at the University of Pretoria where I received a bachelor’s degree and then a master’s degree. After the master’s degree I decided that I wanted to spend more time doing research. I hoped that research would provide some of the answers to questions that continued to come up in discussions on chiropractic theory and philosophy and which were not adequately explained during my studies at Palmer. My master’s thesis was on nerve compression. I then decided to continue with my studies and was accepted for a Ph.D. in neurophysiology at the University of British Columbia, Canada. When I was completing my Ph.D. I was told that it was unethical for a medical physician to work with a chiropractor in any research or clinical setting. It became obvious that if I was interested in clinical research I had to get a medical degree.
TAC: So based on your experience how do you view the role of chiropractic in the current delivery of health care?
Dr. Haldeman: My feeling is the world has changed substantially. Chiropractic is in a period of transition, trying to figure out what it wants to be, what its scope of practice should be and how the profession should be identified by the public. I believe that there is an opportunity right now for chiropractic to become the primary care clinician for people with spinal disorders.
TAC: Does that involve recommendations for surgery or performing surgery?
Dr. Haldeman: No, it’s clearly not in the scope or training of chiropractors to offer surgery or prescribe medication to patients. The primary spine care clinicians would be the first physician seen by patients with a spinal problem. The clinician assuming this role would be expected to have more expertise in the field than anybody else. The expertise would exceed the classic role of chiropractic which has often been limited to providing adjustments. If the chiropractor is to assume this role he or she will be responsible for the first-level care of all patients with spinal disorders. Current evidence based guidelines suggest that exercise, manipulation, and advice are the treatment approaches that should be considered as first level care for patients with uncomplicated spinal pain syndromes.
These treatments all fall within the realm of chiropractic. It is therefore reasonable to consider a chiropractor the first choice clinician for the management of people with spinal problems. This, however, requires chiropractors to be able to diagnose all conditions related to the spine and make recommendations about all treatment options to patients who present with spinal disorders. The primary spine care clinician would be expected to conduct a clinical examination and order diagnostic testing when indicated, be the most skilled clinician in spinal manipulation, exercise training and education and to be able to make appropriate referrals. The primary spine care clinician would have the responsibility to inform patients about their options, and become the patient advocate, for whatever treatment is appropriate even if this includes surgery or medical care.
TAC: Getting off of the subject of primary spinal care clinician, what impact does the chiropractic adjustment have on the patient?
Dr. Haldeman: We do not have full understanding of the impact of the adjustment on the spine and nervous system but there are a few observations that are increasingly clear. For example, we know that manipulation or adjustment has the capacity to reduce back pain, neck pain and headache in a significant portion of patients. This seems to be fairly well accepted and is supported by multiple studies. Most national and international guidelines for back pain and neck pain recognize that spinal manipulation is a reasonable option. We also have evidence that spinal manipulation has a number of biomechanical and neurophysiological effects that have been recorded in both animal and human experiments. The exact clinical importance of these effects is not quite clear yet, but there are a number of theories that are being developed to explain the physiological impact of adjustments. I anticipate that we’ll have considerably greater understanding of the importance of the physiologic and biomechanical role of the adjustment over the next few years as further research is published.
TAC: Can you tell me how Primary Spine Clinicians would assist with informed consent for care?
Dr. Haldeman: What we are talking about is shared decision making, which is somewhat more than informed consent. Informed consent is only one component of shared decision making. Decision making is the process whereby patients make decisions based on all available knowledge on all spine care options. In this situation doctors have the duty to help patients make the decision as to the treatment approach that they prefer.
TAC: Informed decisions...
Dr. Haldeman: Informed decisions. The situation we aretalking about is based on the assumption that chiropractors are acting as primary spine care clinicians. When a patient seeks the care of a chiropractor the most important service is to determine the nature of his or her problem. Most patients will then ask “What do I do next?” It is up to the chiropractor to have sufficient knowledge to provide information regarding all the potential options to the patient. The patient, with the understanding and knowledge of the chiropractor, can then make appropriate decisions about their care.
TAC: What you’re saying is it’s a professional way of representing a service.
Dr. Haldeman: It is also what patients are starting to demand. There are over 200 treatment options available to people with spinal pain. Currently the most frequent approach to this dilemma is to say to a patient, “There are multiple different types of doctors and specialists who offer treatment to patients with spinal disorders. Everybody considers themselves an expert but doctors rarely agree on what the appropriate treatment approach should be. There is very little communication between doctors with different ideas and you, as a patient, have to decide which treatment approach you want to try". That clearly is not a very professional way of helping patients. The recommended approach is for a doctor to discuss all treatment options with patients. This is not just an issue within the chiropractic profession. Similar discussion can be seen in medical and surgical journals. As noted in the presentations at this meeting, the role of the doctor is to examine the patient, reach a diagnosis, inform a patient about the consequences of that diagnosis, how accurate it is then discuss treatment options. As the doctor works through these steps with the patient at each point the patient is informed what the harms are for each of the options, the benefits of the different approaches as well as the likelihood of getting better or prognosis. This information is no more than a reasonable person would normally require if he or she was shopping for some other product. There’s nothing unique any more about health care, it used to be whatever the doctor told you that’s what you did, but patients today are now demanding that they have a say in what decisions are made.
TAC: What is the World Spine Care Mission?
Dr. Haldeman: World Spine Care is a multinational, charitable, non-profit organization bringing effective spine care to communities in need worldwide. World Spine Care has been created to fill the profound gap in the treatment of musculoskeletal conditions that exists in the developing world. It consists of health professionals – chiropractors, medical specialists, surgeons, physiotherapists and others – coming together to build a sustainable capacity for effective spinal care in communities around the globe. World Spine Care was conceived in 2008 and officially launched in early 2010. WSC is planning to build sustainable capacity for effective spinal care in the communities in which it works, combining primary care with education and outreach. WSC is also developing the fundamental clinical tools needed to bring effective spine care to the developing world.
TAC: What are the components or programs that World Spine Care is establishing to achieve these goals?
Dr. Haldeman: There are 4 basic programs that the World Spine Care are instituting:
- Establishment of clinics in underserved communities. The clinics will initially be staffed by volunteer clinicians. The primary spine care clinicians would include chiropractors who will be asked to spend 3-12 months at the clinics. Surgeons and medical specialists will be asked to spend 2-4 weeks offering their services to those patients with more severe pathology. The WSC clinics will be the focal point for the delivery of primary care, the training of front line health care workers, advanced training of local health care professionals, and a conduit between clinic patients and specialized WSC-delivered medical intervention as required. Over time, WSC will transition the operation of clinics over to host health care systems, with the continued partnership and support of WSC.
- Development of a universal evidence based model for spine care. This will be based on the concept of a primary care spine clinician who will be responsible for examination of patients with spinal disorders, provide non-surgical, non-pharmaceutical care, order appropriate testing and make referrals to surgical and medical specialists when appropriate. WSC is developing the primary tools needed for the delivery of effective spine care in underserved communities. The first and fundamental tool in the WSC toolkit is the WSC clinical model of care which provides integrated, inter-professional protocols for screening, assessment and treatment of the full spectrum of spinal disorders. The WSC clinical model of care could be a primary tool used by health care professionals for the delivery of spine care in all communities.
- Education of local communities and health care professionals on the management and prevention of spinal disorders. This will involve general education of patient populations and the communities in which WSC works on simple self-care approaches to spine care and injury prevention and the training of front line health care workers in the use of WSC spinal care protocols. WSC is also planning to provide scholarships to exceptional students from host regions, to obtain professional accreditation in chiropractic, physical therapy or spinal surgery from collaborating academic institutions.
- Research. There are a number of specific research projects currently being contemplated. This will include an initial epidemiological study evaluating the prevalence, burden and care of spinal disorders among residents of Shoshong. There is also an integrated research component tracking the nature and frequency of musculoskeletal conditions occurring in patients who are living with HIV / AIDS. The WSC research team will also evaluate the efficacy of the screening, assessment and treatment protocols used in this community and the model of care delivery.
TAC: Is this project in need of funding, or is this something that needs participants to volunteer their time and energy?
Dr. Haldeman: All of the above. If we don’t get enough funding we won’t be able to continue, so right now we’re in a strong fundraising mode and trying very hard to get the resources necessary to make this work. With sufficient funding the program cannot function without volunteers willing to spend time in the clinics. We, however, have received sufficient funding to have people on the ground. We have clinicians who are currently seeing patients in Botswana and on their way to India. This is not a start-up operation anymore; we are actually actively seeing patients.
TAC: So chiropractors would be considered spinal care physicians in this model and would be acceptable as applicants.
Dr. Haldeman: Right now the clinicians who have initially volunteered to staff the clinics as primary care clinicians and provide treatment are chiropractors. In the facilities where the primary spine care clinicians will be seeing patients, they are given all the rights and privileges of other physicians in these communities. There has been no difficulty getting this commitment from the hospitals where the clinics are being established. The WSC clinicians are very well accepted into the community of health care clinicians in these facilities.
TAC: Who are some of the most prominent figures sponsoring World Spine Care?
Dr. Haldeman: There has been an amazing interest and commitment in the WSC program. Archbishop Tutu, Nobel Prize laureate, agreed to serve on the WSC advisory board and support the program. Elon Musk, co-founder of Paypal and current CEO and founder of SpaceX and Tesla Motors is currently serving on the WSC board. WSC has been endorsed by the Bone and Joint Decade, the International Society for the Study of the Lumbar Spine, the North American Spine Society, the European Spine Society, the World Federation of Chiropractic and a number of other organizations. Funding has been received from the Skoll Foundation, Musk foundation and the Bechtel Trust, the British, Kootenay and Ontario Chiropractic Associations as well as CMCC and Palmer College. The amount of support has shown that there is a real interest and support for the goals of World Spine Care.
TAC: So, what are some of the long-term goals for the World Spine Care Mission?
Dr. Haldeman: The long-term goal is to improve the health of people with spinal disorders in underserved communities and to provide a model of care that could be used in other settings. It is a broad and all-encompassing program. Jeff Outerbridge, a chiropractor volunteer from Ottawa, Canada is currently in Botswana and seeing patients. He is the WSC clinical coordinator and is establishing the clinical protocols with the assistance of faculty from Palmer College and CMCC. The government of Botswana has given WSC all the space needed at the hospital and has also given World Spine Care clinics all the staffing we need for translation and similar administrative needs of the clinics.
TAC: How does one support or become a member?
Dr. Haldeman: World Spine Care will only succeed if there is widespread support by individual clinicians, institutions, organizations, foundations and companies. It is a volunteer organization and will only succeed if volunteers come forward and offer support and services. World Spine Care has instituted a program where individual clinicians or their patients can support the program by becoming a non-voting member. The support through membership can be done online by going to the World Spine Care website. An interested chiropractor could also volunteer on a committee, consider fundraising for WSC by contacting philanthropists or industry leaders, or volunteer time in one of the clinics or centers. There are many ways in which a chiropractor can become involved. Anyone who wants to be involved should just contact WSC and serve in any way they can.
TAC: What is the website to learn more information?
Dr. Haldeman: www.worldspinecare.org
TAC: Dr. Haldeman, could you tell me about your experience seeing patients?
Dr. Haldeman: I practiced as a chiropractor for 14 years in South Africa and in Canada. I am a neurologist by medical training and have never been a surgeon. My main interest at this time is to help people with spinal disorders and I strongly believe that this can only be achieved with a multidisciplinary evidence based approach to the problem. Such an approach, as noted during the presentations at this meeting, requires the active participation of chiropractors, their associations and institutions.
TAC: Thanks for your time Dr. Haldeman.
This interview followed the FCA National Seminar in Orlando, 2011, and makes some references to the informed consent seminar presented.